Mission Statement Provider and Member Experiencedhhs.ne.gov/Documents/HeritageHealth...
Transcript of Mission Statement Provider and Member Experiencedhhs.ne.gov/Documents/HeritageHealth...
Mission Statement
Year-End Review
Quality Review
Provider and Member Experience
Performance Management
Committees and Forums
Director’s Tour of the Health Plans
Heritage Health is a person-centered approach to administering Medicaid benefits that provides
Medicaid and CHIP members a choice of a single plan that provides all of their physical health,
behavioral health, and pharmacy benefits and services in an integrated health care
program. Integrated care through Heritage Health will improve member health outcomes, reduce
costly and avoidable care, decrease reliance on emergency and inpatient levels of care by providing
evidence-based care options that emphasize early intervention and community-based treatment,
addresses social determinants of health, and improves the financial sustainability of the system.
3,583,726 health claims paid in 2017, totaling $720,136,725.91
3,416,633 pharmacy claims paid in 2017 totaling $223,579,643.15
Health plan enrollment
Value-added services
Community engagement across the state
Communication to stakeholders
Value the Heritage Health Plans bring to the program and across the State
Managed Care brings many value-added services to members. A few highlights for new benefits in 2018 include:
24hr Nurse Advice Line Mobile app to view resources Breast Pumps, Baby Showers and Diaper Days: education on prenatal and postpartum care for
mothers and newborn and pediatric care for babies; rewards available ConnectionsPlus: free cell phone for members without reliable access to a telephone Hope Bear: incentive program for participation in post-hospital appointments
Managed Care brings many value-added services to members. A few highlights for new benefits in 2018 include:
Purchase of Breast Pumps Healthy First Steps®: Ensures that mom and baby receive good medical attention Baby Showers: Education on prenatal and postpartum care; rewards available 24 Hour Crisis and NurselineSM Health4Me Mobile App: To review resources
Managed Care brings many value-added services to members. A few highlights for new benefits in 2018 include:
Free Car Seats: Free for pregnant members Pursuant Kiosk: Complete Health Risk Assessment at a local Walmart kiosk to receive Walmart
gift card Family Support Specialists: Families receive counseling through a partnership with Nebraska
Family Support Network Community Room/Concierge: Offers community support needs such as free meeting spaces,
personal assistance, and computer kiosks
Statewide participation with various partners
WellCare Dental DayNTC Vision Van
UHC CommunityBaby Shower
Stakeholder Meetings
Member outreach/event
Provider Orientations
COMMUNITY CONNECTIONS11
• Updates on MCOs’ communications and education efforts are now required in their bi-weekly meetings with Heritage Health
• These new requirements will help Heritage Health gauge the success of these efforts
• These efforts will similarly help identify opportunities to improve the program
An EQR is the analysis and evaluation of aggregated information on quality, timeliness, and access to Medicaid-covered services.
Federal regulations set parameters that states must follow when conducting an EQR of contracted health plans.
The EQRO must review the MCO’s compliance with standards for access to care, structure and operations, and quality management
The EQRO must also validate performance measures and performance review projects
Quality of Care - External Quality Review Organization (EQRO)
Collaborative project between the state, MCOs, and the EQRO to improve Nebraska Medicaid population health
Heritage Health currently has three in development:
Follow-up after an emergency department visit
Mental illness (FUM)
Alcohol and other drug dependency (FUA)
17p
Hydroxyprogesterone caproate
Tdap
Contractual requirement for 1.5% withhold of total revenue
Funds can only be earned by meeting QPP measures
Year Two – Shifting to a mix of administrative and clinical measures
These measures are revisited annually and can include administrative and/or clinical measures that reflect the MCO business processes, as well as CMS Medicaid Adult and Child Core Measure sets, HEDIS measures, and MLTC-identified measures.
Quality Performance Program (QPP) Measures
Nearly 70 percent of NTC’s provider survey respondents would recommend NTC to other physician practices
Over 70 percent of solo practitioners would recommend NTC to other practices
With physicians practicing 16+ years, over half would recommend NTC to other physician practices
Access to Case Management is an area to improve
UHC’s 2017 provider survey saw an increase in response rate over 2016 with more respondents replying
Percentage of respondents who identified as “satisfied” and “very satisfied” increased over 2016
Overall provider satisfaction increased nearly 10 percent in the last year
Areas of high satisfaction included:
Specialty networks
Timeliness of information exchange
Clinical practice consultant
Provider administrative guide
WellCare’s provider survey had a total response rate of 13.9 percent
Responses came primarily from primary care physicians and specialists (74 percent)
Overall satisfaction was similar to other health plans, with 64.6 percent saying they would recommend WellCare to other physician practices
Respondents had a nearly identical satisfaction level to Nebraska Total Care when it came to Access to Case Management
CCC Rate – getting needed care: 92 percent
CCC Rate – getting care quickly: 96 percent
Child Rate – getting needed care: 90 percent
Child Rate – getting care quickly: 93 percent
Adult Rate – getting needed care: 87 percent
Adult Rate – getting care quickly: 89 percent
CCC Rate – ease of getting care: 94.6 percent
CCC Rate – getting care quickly: 87.2 percent
Child Rate – ease of getting care: 93 percent
Child Rate – getting care quickly: 86.3 percent
Adult Rate – ease of getting care: 85.8 percent
Adult Rate – getting care quickly: 87.7 percent
CCC Rate – ease of getting care 93 percent
CCC Rate – getting care quickly 91.5 percent
Child Rate – ease of getting care 83.3 percent
Child Rate – getting care quickly 86.2 percent
Adult Rate – ease of getting care 85.8 percent
Adult Rate – getting care quickly 85.5 percent
Improved health outcomes
Enhanced integration of services and quality of care
Emphasis on person-centered approach, care management, enhanced preventive services, and recovery-oriented care
Reduced rate of costly and avoidable care
Goals MLTC set for Heritage Health
Emphasis on person-centered approach and care management
A member enrolled in case management in October 2017 with a desire to lose weight. Member has osteoarthritis, obesity and depression. She approached her Case Manager (CM) with a desire to lose weight. At the time her BMI was 49.98. The member took advantage of NTC’s value-added benefits and enrolled in weight watchers and joined the YMCA. She actively participates in case management and her CM encourages increased activity and adhering to her diet. As of 2/26/18, the member has lost more than 62 pounds and her BMI is currently 39.9.
The member is very proud of her progress and reports that she feels better and has a more positive outlook. Prior attempts with Weight Watchers had not been successful, but the support of her CM made the difference this time.
A 58-year-old WellCare of Nebraska Medicaid member called the WellCare Community Assistance Line (CAL) to request help finding food services.
CAL is a referral tracker database with thousands of community organizations and activities that are available to low-income families and children such as food, education and utility assistance; transportation, disability and homeless services; and support groups and childcare services. It is available for WellCare members as well as the public throughout Nebraska.
Community Liaisons Brent and Sylvia referred the member to the Salvation Army in Norfolk for assistance. The organization was able to provide the member the food she needed, when she needed it. The member expressed that she was very happy with the assistance CAL offered her and she would use it again in the future if the need arised.
Easy access to needed services and helpful MCO staff
This very ill member was having difficulty navigating her medical care. She is facing multiple life threatening medical diagnoses, including breast cancer. She recently moved to Nebraska to be closer to family. Her experience with the health care system in Nebraska has been very different than what she was familiar with in her previous state. She was feeling confused and frustrated which was further complicated by her language barrier. Her primary language is Arabic.
The Care Manager listened to this member to identify all her needs and began coordinating care. She consulted UnitedHealthcare pharmacy staff regarding several essential prescriptions this member reported she had not received from the pharmacy. UnitedHealthcare pharmacy staff reached out to her doctor in order to have the prescriptions refilled. The member also received education about the Phone-A-Pharmacist program offered by the pharmacy. The program allows the member to speak directly to an Arabic-speaking pharmacist by telephone to confirm she has and understands all her needed prescriptions. The Care Manager also contacted the primary care physician’s office to schedule her pre-operation appointment, scheduled an interpreter to translate the appointment, and arranged transportation for the appointment through Intelliride.
The member received personal attention to assist her in navigating the health care system anddecrease language and transportation barriers in order to get the medical care she needsin a timely manner. This member now has the information she needs to communicate with her providers, a key component to receiving quality healthcare.
Personalized attention to coordinate care, leading to improved health and an increased quality of life.
Data from the 50+ contractually required reports
Evaluating and assessing whether the reporting elements are effective and assessing what could be done differently
Plan management team is digging into the data along with MLTC’s data and analytics team
Continued evolution of the public dashboard
Over 800 contractual requirements overseen
In order to produce better, more accurate data, MLTC started using new reporting templates as of January 2018
The updated templates resulted from a collaborative process with the MCOs through 2017 to streamline reporting
Certain reports were consolidated and data definitions were clarified
Reports updated: Grievances, Appeals, Claims, and Behavioral Health
• In 2017, clean claims data was gathered on an ad hoc basis
• Beginning this year, Heritage Health is gathering information on clean claims via standardized reporting templates, which have been shared with the MCOs
• New methodology in reporting will provide more accurate data and make it possible to compare the three MCOs in terms of clean claims
Review of over-the-counter (OTC) medications
Create a comprehensive list of OTCs that are preferred by Medicaid
Prior authorization for DME based on price limits is now complete
Offers consistency across the plans and eases administrative burden on providers
Common form to change primary care provider selection for membersHeritage Health is now actively seeking feedback on this, with plans to finalize in April 2018
Prior authorization for wheelchairs Engagement with Administrative Simplification Committee was directional
Plans in place to engage with MCOs and DME association to revise forms
Administrative Simplification Projects in Process
Touring each of the health plans on March 22
These tours will include touring facilities, seeing call centers in action, receiving
presentations on each Care Management program, Utilization Management
program, and Quality Management program
Looking forward to meeting other providers in the coming weeks as well
dhhs.ne.gov
Medicaid & Long-Term Care
Dr. Matthew Van Patton, Director